4 Learning ObjectivesLearner will be able to identify the stages of pressure ulcersLearner will be able to identify patients at risk for pressure ulcersLearner will be able to identify 3 ways to decrease risk and incidence of pressure ulcersLearner will be able to identify 3 complications of pressure ulcers

5 Let’s Start With A Case StudyGrace is an 84 year old female who was recently admitted into the hospital with a diagnosis of Pneumonia.She has been weak, she used a cane before admittance in the hospital. She now is only mobile per wheel chair.She also is an uncontrolled Type II Diabetic (Non-Insulin Dependent)HOW WILL YOU PREVENT HER FROM DEVELOPING PRESSURE ULCERS?Doheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from

10 Let’s Review… What are pressure ulcers??Also known as: Pressure/Bed SoresAreas of cellular necrosis and skin breakdown most common over bony prominencesCan occur anywhere on the bodyMost Common Sites: Sacrum, HeelsFor Educational Purposes, NIHLippincott Williams and Wilkins, 2011

11 Incidence of Pressure UlcersEstimated: 1 mill/yr; annual cost = $1.6 billionThe elderly account for > 60% of decubitus patientsSince 2008, hospitals are not able to be reimbursed for the care of Stage III or IV pressure ulcers that the patient acquires during their hospital stay63% increase in hospitalized patients with pressure ulcers between 1993 and 2003There has been no sig decrease in pressure ulcers in the last 10 yearsMost often seen in elderlyBedridden; Chair Bound9 out of 10 patients were covered by a government program (Medicare or Medicaid)In 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnosesAnders, 2010; Sage Products Inc (2003)Mereck Manual of Geriatrics, 2000; Krasner (2008).

16 Prevention BEGINS AT FIRST CONTACT Turn patient at least every 2 hoursDo not place pts in a 90 degree lateral positionPuts more pressure on greater trochanter and lateral malleolusDon’t elevate HOB > 30 degrees (except when eating) to minimize shearing forcesAvoid Fluorescent Light, it casts a blue tint to skin (Capezuti, 2008)Check skin of high risk patients for changes in:Color, turgor, temp, and sensation.Mereck Manual of Geriatrics, 2000

17 Prevention Cont. Patient should not sit more than 2 hoursSitting position puts increased pressure on ischial tuberosities.Reposition patient every hour in chairTeach patient to shift weight every 15 minutesDo not use pillows/ rubber doughnutsKeep skin surface clean and dry (Meticulous skin care)As few pads as possible should be usedMain Points:Keep pressure off the area of breakdownClean and dress the woundMaintain good nutritionMereck Manual of Geriatrics, 2000

21 Case StudyGrace has a history of COPD and has smoked 1 PPD for 22 years, but quit 7 years ago.Her Diabetes has progressed and due to complications her Left foot was amputated.On the last shift a small Stage I pressure ulcer was also discovered.

22 What complication should the nurse most focus on preventing?A. Progression of the Ulcer to a new stage B. Increased Length of Stay C. Infection D. Sepsis E. All of the Above F. A and B onlyClick Here To ReadCase Study Narrative

23 Stages of Pressure UlcersStaged according to depth of damageBright Hub Inc, Public Domain ImageMereck Manual of Geriatrics, 2000

24 Suspected Deep Tissue InjuryMaroon or purple intact skin or a blood filled blisterCause: shearing or pressure on the underlying soft tissueBefore discoloration occurs, the area may be:PainfulMushy, firm, or boggyWarmer or cooler as compared to other tissueNational Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Abrass, 2004

25 Stage IAn area of intact skin that does not blanch and is usually over a bony prominence.NON-BLANCHABLEDarkly pigmented skin may not show blanching but its color may differ from the surrounding area.The area may be painful, firm or soft, or warmer or cooler when compared to the surrounding tissue.National Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Abrass, 2004

26 Stage II A superficial partial thickness woundPresents as a shallow, open ulcer without slough and with a red and pink wound bed.This term shouldn’t be used to describe:Perineal dermatitis, maceration, tape burns, skin tears or excoriation .Only use to describeAn abrasion, a blister, or a shallow crater that involves the epidermis and dermis.National Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Abrass, 2004

27 Stage III A full-thickness wound with tissue loss.The subcutaneous tissue may be visible but muscle, tendon, or bone is not exposed.Slough may be present but it does not hide the depth of the tissue loss.Undermining and tunneling may be present.Bone/Tendon are NOT visibleNational Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Abrass, 2004; NPUAP, 2007

31 Case Study Cont. Which of the following is Grace most at risk for?FrictionShearingMacerationLacerationClick Here To ReadCase Study Narrative

32 Case Study Grace became incontinent of bowel and bladder.Click Here To ReadCase Study NarrativeGrace became incontinent of bowel and bladder.She has a decreased appetite and has become more confused since the last shift.A urine specimen was obtained and results show she has a UTI.

33 What measures can you take to prevent progression and development of pressure ulcers?

45 Nursing Implications Krasner, 2008Diligent assessment and documentation of the condition of the skin of all patientsUse of supplements and feeding assistance devices as neededONLY pressure ulcers should be st aged; Wounds of other etiologies:(venous insufficiency, arterial, diabetic/neuropathic foot ulcers, trauma, etc) should be described as partial or full thickness or other appropriate system of documentationPressure ulcers are not staged in a reverse mannerEx. A Stage IV does not progress to a Stage III, II or I.The stage remains the same throughout the healing process.In deeper stages (Stage III and IV) tissue destroyed is replaced by granulation tissue and ultimately scarKrasner, 2008

47 CASE STUDY CONT.What aspect of Grace’s existing condition is the most influencing factor for increasing her risk for pressure ulcers?Pneumonia/COPDDiabetesVenous InsufficiencyLack of MobilityNone of the AboveAll of the AboveClick Here To ReadCase Study Narrative

48 Case Study ConclusionsPress ulcers can increase morbidity and risk for complicationsGrace represents a typical patientDocumentation and thorough assessment is a necessityFOR A VIRTUAL TOUR OF SKIN BREAKDOWN SEE NEXT SLIDEDoheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from /.

50 Did you meet the objectives??Identify the stages of pressure ulcersIdentify patients at risk for pressure ulcersIdentify 3 ways to decrease risk and incidence of pressure ulcers (prevention)Identify 3 complications of pressure ulcersClick the link if you wantto review!